Endovascular therapy including thrombectomy for acute ischemic stroke: a systematic review and meta-analysis with trial sequential analysis

One of the primary strategies for the management of acute ischemic stroke is intravenous (IV) thrombolysis with tissue plasminogen activator (t-PA). Over the past decade, endovascular therapies such as the use of stent retrievers to perform mechanical thrombectomy have been found to improve functional outcomes compared to t-PA alone. We aimed to reassess the functional outcomes and complications of IV thrombolysis with and without endovascular treatment for acute ischemic stroke using conventional meta-analysis and trial sequential analysis. Pooled relative risks (RR) and 95% confidence intervals (CI) were calculated for the effect of IV thrombolysis with and without endovascular therapy on functional outcome, mortality and symptomatic intracranial hemorrhage (SICH). Trial sequential analysis was done to strengthen the meta-analysis. We analyzed six randomized controlled trials involving 1943 patients. Patients who received IV thrombolysis with endovascular treatment showed significantly higher rates of excellent functional outcomes (modified Rankin Scale [mRS] 0-1) (RR, 1.75 [95% CI, 1.29-2.39]) compared to those who received IV thrombolysis alone. A similar association was seen for good functional outcomes (mRS 0-2) (RR, 1.56 [95% CI, 1.24-1.96]). Trial sequential analysis demonstrated endovascular treatment increased the RR of a good functional outcome by at least 30% compared to IV thrombolysis alone. There was no significant difference in all-cause mortality for mechanical thrombectomy compared to IV thrombolysis alone or the incidence of SICH at 3 month follow-up. Endovascular treatment is more likely to result in a better functional outcome for patients compared to IV thrombolysis alone for acute ischemic stroke.